One on One

The One-On-One Column provides scientifically

supported, practical information for personal trainers
who work with apparently healthy individuals or
medically-cleared special populations.

COLUMN EDITOR: Paul Sorace, MS, RCEP, CSCS*D

Exercise Program
Guidelines for Persons
With Chronic Nonspecific
Low Back Pain
Peter Ronai, MS, RCEP, CSCS*D, NSCA-CPT*D1 and Paul Sorace, MS, RCEP, CSCS*D2
1
Exercise Science Department, Sacred Heart University, Fairfield, Connecticut; and 2Hackensack University Medical
Center, Hackensack, New Jersey

SUMMARY
CHRONIC NONSPECIFIC LOW
BACK PAIN (CNSLBP) CAN BE A
DEBILITATING CONDITION. THE
MAJORITY OF U.S. CITIZENS WILL
EXPERIENCE LOW BACK PAIN
THAT MAY BECOME CHRONIC AT
SOME TIME IN THEIR LIVES. HOW-
EVER, EXERCISE TRAINING HAS
MANY BENEFITS AND CAN BE
WELL TOLERATED WITH SOME
MODIFICATIONS. THIS COLUMN
WILL DISCUSS EXERCISE PRO-
GRAMMING FOR PERSONS WITH
CNSLBP.
ersons with chronic nonspecific
(PA) guidelines for apparently healthy
adults can apply to individuals with
CNSLBP and provide exercise profes-
sionals with evidence-based tools and
scientific rationale to help their clients
adopt a more physically active lifestyle
(1,3,19). This column will discuss PA/
exercise program recommendations
for medically cleared clients with
CNSLBP who have been discharged
from formal physical therapy and reha-
bilitation. Exercise professionals who
ignore their client’s reports of new or
worsening symptoms or fail to refer
them to their physician and/or health
care provider can be held negligent.
Clients with CNSLBP can participate
in and benefit from the same types of
(e.g., hypertension and type 2 diabetes)
may be present in this population. Cli-
ents should complete a thorough pre-
activity screening with an exercise
professional (1). Exercise professio-
nals should determine client’s risk(s)
according to the guidelines set by
the American College of Sports Med-
icine (1). Depending on their level of
risk, the client may need a medical
examination and/or a physician-
supervised graded exercise test before
being medically cleared to begin an
exercise program.
EXERCISE TESTING
Preactivity exercise testing helps exer-
cise professionals determine their cli-
ent’s physical fitness, physical activity

P
low back pain (CNSLBP) often
experience physical activity
intolerance, physical deconditioning,
and follow a more sedentary lifestyle
than individuals without CNSLBP
(6,17,18,20). New physical activity
exercise programs as persons without
CNSLBP (7–11,15,17).
PREACTIVITY SCREENING
Because many persons with CNSLBP
are sedentary and experience physical
activity intolerance, other health issues
tolerance levels, functional capacity,
and establish realistic PA/physical fit-
ness program goals (1). Client symp-
toms, tolerance and comfort should
dictate which exercise testing modes
and protocols are selected (5,15,17).

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One on One

Table 1
Physical activity and exercise guidelines for apparently healthy adults

Fitness Mode Frequency Intensity Time/duration Sets Repetitions

component

Cardiorespiratory AT—Walking, $ 5 d/wk Moderate 30– Moderate

fitness cycling, Moderate 60% of $30 min/d or
stepping, intensity, $3 V̇O2Reserve or $150 min/wk,
NuStep, d/wk vigorous vigorous vigorous
recumbent intensity, or $60% $20 min/d or
cycling a combination V̇O2Reserve $75 min/wk
of both or
a combination
of both
moderate and
vigorous to
achieve a total
energy
expenditure
of 500–1,000
MET min/wk
Resistance Machines, free 2–3 d/wk or 2–3 Novice: 60–70% #1 h 2–4 Exercise Strength: 8–12.
training weights, days per of 1RM. sets per major Endurance:
resistance muscle group Advanced: muscle group 15–20.
tubing, body if using a split $80% of (can be done Middle aged
weight. 8–10 routine 1RM. Middle as either one and older
Exercises for all protocol. aged and exercise or individuals:
major muscle Allow $48 h older more than 10–15
groups. rest between individuals one exercise
Multiple and workouts for 40–60% of for that
single joint each muscle 1RM. muscle group.
exercises are group Exercises Single set
recommended should be protocols are
performed to effective for
fatigue but novices
not failure.
Flexibility training Either static $2–3 d/wk Stretch to point Hold each Preceded by 2–4 per stretch
stretching, of light stretch for either passive
dynamic pressure $10–30 s, 30– or dynamic
stretching, or 60 s for older stretching,
proprioceptive adults and a warm-up
neuromuscular accumulate at activity
facilitative least 60 s per
stretching stretch
Neuromotor Gait, balance, $2–3 d/wk 20–30 min per
training yoga and tai session
chi activities
AT 5 aerobic training; MET 5 metabolic energy; 1RM 5 one repetition maximum.

Adapted with permission from American College of Sports Medicine (3) and U.S. Department of Health and Human Services (19).

Cardiorespiratory fitness testing using
either a treadmill, bicycle, or step
ergometer with either a ramp or incre-
mental protocol has been well toler-
ated and is an effective evaluation
tool for persons with CNSLBP (5,15).
In addition, the 6-minute walk test has
been proven an effective field test of
cardiorespiratory fitness in persons
with CNSLBP (15). Muscle strength
testing using a multiple repetition max-
imum has been well tolerated and an
effective tool for measuring current
strength levels, determining training
loads and measuring postprogram
strength increases in clients with
CNSLBP (8–10). The use of standard
ratings of perceived exertion (RPE) or

34 VOLUME 35 | NUMBER 1 | FEBRUARY 2013

the OMNI rating of perceived exertion
for resistance exercise (OMNI-RES 10)
can approximate intensity of client
effort during both strength testing
and resistance training (RT), respec-
tively (1,16). The “timed up and go”
and multiple repetition sit to stand tests
are appropriate tools for measuring
neuromotor performance in older indi-
viduals (60 years and older) with
CNSLBP. The inability to tolerate pro-
longed sitting, standing, frequent bend-
ing (trunk flexed postures), and pain
exacerbations can negatively affect cli-
ent test tolerance and performance ef-
fort(s) (16).
AEROBIC TRAINING
Aerobic training (AT) has been well
tolerated in persons with CNSLBP
(9,12). Walking, cycling, step ergome-
try, swimming, elliptical and aquatic
exercises are acceptable forms of AT
(15,17). An appropriate goal for clients
with CNSLBP is to try and accumulate
$30 minutes of moderate intensity AT
on most ($5) days of the week. Ini-
tially, this goal might be best tolerated
in 10-minute episodes, 2–3 times per
day in more deconditioned persons.
Subsequently, total daily time in a single
episode can be increased over a few
weeks (15). Focus on increasing dura-
tion before intensity, building to lon-
ger periods of sustained aerobic
activity (e.g., 30 continuous minutes
or more). An exercise intensity equiv-
alent to an RPE of between 12 and 15
(6–20 scale) is appropriate for persons
with CNSLBP. Client pain and dis-
comfort, other symptoms, and most
comfortable postural positions should
dictate exercise mode selections and
modifications.
RESISTANCE TRAINING
Clients with CNSLBP are encouraged
to follow RT guidelines for apparently
healthy sedentary individuals (1,3,15).
Clients should perform 8–10 exercises,
emphasizing all major muscle groups,
using a variety of modalities (free
weights, machines, resistance exercise
tubing, and body weight/calisthenics).
Initially, RT should be performed on
2–3 nonconsecutive days per week
(1–3,15). An initial training intensity
that is equivalent to either an RPE of
12–13 (of 20) or 3–5 (of 10) on the
OMNI RES scale is appropriate. If tol-
erated, progress to an intensity level
equivalent to a 14–16 RPE or 4–5
OMNI RES scale. Clients with
CNSLBP are advised to use lower
intensity higher repetition protocols
to maximize muscular endurance, to
avoid exercising initially on unstable
surfaces (BOSU Balls, etc.) and to
maintain proper exercise technique
and posture (15). Load and intensity
progressions should be dictated by cli-
ent tolerance. Lumbar extension resis-
tance exercises increase back extensor
muscle strength and should be included
in conditioning programs for persons
with CNSLBP (15). Extension exer-
cises can be progressed from easier
(lying prone on floor with arms at
sides) to more challenging (the swim-
mer and superman on the floor or a sta-
bility ball), to “Bird-dogs” on the floor
in quadruped position (15). Periodized,
progressive, multiple set RT programs
have produced significant increases in
strength in persons with CNSLBP that
were comparable to apparently
healthy individuals (8–10). Clients with
CNSLBP are encouraged to follow an
intensity progression protocol similar
to the “two for two” rule (increase
intensity after 2 or more repetitions
per exercise set are performed beyond
the goal repetitions for 2 consecutive
sessions) if tolerated (2). Although
single set RT exercise protocols have
produced significant strength in-
creases in sedentary and untrained in-
dividuals, progressing to a protocol of
2–4 sets per exercise is recommended
as tolerated (1–3). For additional re-
sources that discuss both CNSLBP
management and back conditioning
exercises refer to McGill (13,14).
FLEXIBILITY AND NEUROMOTOR
TRAINING
A series of flexibility activities for each
major muscle-tendon unit is recom-
mended. Clients should hold each
stretch for between 10 and 30 seconds
and accumulate a total stretch time of
at least 60 seconds per exercise. Lon-
ger stretching durations of between 30
and 60 seconds per repetition may be
warranted for older individuals.
Stretches should be preceded by light
aerobic activity (11–13 RPE or 4–5
OMNI Scale) for 8–10 minutes. Static,
dynamic, and proprioceptive neuro-
muscular facilitation stretching are all
acceptable as tolerated (1,3). Ham-
string, hip flexors, and anterior shoul-
der girdle muscle flexibility exercises
should be emphasized (1,15). In addi-
tion, clients with CNSLBP generally
should:

Table 2
Special exercise considerations for clients with CNSLBP*
! Exercises/activities that are high impact (e.g., running) should be avoided or introduced gradually with caution.
! Trunk exercises (abdominals, back, and hips) should be avoided when acute low back pain is present.
! Consider multiple exercise modes and positions to find what is most comfortable for the person.
! Educate the client on postural exercises to minimize low back stress (e.g., proper gait and seated position).
! Avoid any activity that elicits low back pain.
*Information obtained with permission from Simmonds and Derghazarian (17).

Strength and Conditioning Journal | www.nsca-scj.com 35

One on One
! Avoid flexion (trunk bending) exer-
cises soon after awakening.
! Avoid standing toe touch exercises/
stretches.
! Emphasize balance spinal flexor
and extensor muscle range of motion
exercises (15).
Exercise programs should be modi-
fied if clients experience increasing
symptoms with either flexion or
extension.
Exercises, which improve balance, gait,
and proprioception, such as tai chi and
yoga, are recommended for older indi-
viduals to maintain independent phys-
ical function and prevent falls. Training
sessions lasting 20–30 minutes on at
least 2–3 d/wk are appropriate for
older individuals (1,3) and have been
well tolerated in persons with
CNSLBP (4,12). Exercise professionals
should modify exercise selection, inten-
sity, and volume if clients experience
increased pain or fatigue and commu-
nicate with and refer their clients
back to their physician and/or health
care provider. Table 1 summarizes
ACSM PA/exercise guidelines for
apparently healthy individuals. There
are some special exercise considera-
tions (Table 2) for clients with
CNSLBP that exercise professionals
should be aware of.
SUMMARY
Persons with CNSLBP derive the
same physical health and quality of
life benefits from individualized exer-
cise programs as apparently healthy
participants without CNSLBP. Com-
prehensive, individualized, progressive
exercise programs consisting of AT,
RT, flexibility, and neuromotor train-
ing have been proven effective in
enhancing physical activity tolerance
and function and well tolerated in per-
sons with CNSLBP. Exercise profes-
sionals should perform within their
scope of practice by obtaining medical
clearance from their clients, monitor-
ing clients for signs of overexertion,
communicating regularly with their
client’s physician or health care pro-
vider and by working with clients
who have been discharged from formal
physical therapy and rehabilitation.
36 VOLUME 35 | NUMBER 1 | FEBRUARY 2013
Conflicts of Interest and Source of Funding:
The authors report no conflicts of interest
and no source of funding.
Peter Ronai is an Associate Clinical
Professor in the exercise Science Depart-
ment at Sacred Heart University.
Paul Sorace is a clinical exercise
physiologist for The Cardiac Prevention
and Rehabilitation Program and the
program coordinator for The Bariatric
Rehabilitation Program at Hackensack
University Medical Center in Hackensack,
New Jersey.
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